aboriginal health in aboriginal hands - flinders · pdf fileaboriginal health in aboriginal...

Community-controlled Comprehensive Primary Health Care @ Central Australian Aboriginal Congress

Flinders UniversitySouthgate Institute for Health, Society & Equity

Aboriginal health in Aboriginal hands

What this report is about . . .

C omprehensive primary health care (PHC)—which focuses on the whole patient,

not simply a disease state—has been the global ‘gold standard’ for addressing

community health problems since the 1970s, including in Australia. Ideals are rarely put

to the test, however.

In 2010 the National Health and Medical Research Centre (NH&MRC) funded the

Southgate Institute for Health, Society and Equity at Flinders University to

investigate how well community health services in South Australia are conforming to

the principles of comprehensive PHC and the reasons for their success or otherwise.

Six community health services were selected for intensive study over several years: 5 in

South Australia and 1 in Alice Springs in the Northern Territory.

Of these six, the Central Australian Aboriginal Congress (‘Congress’) in Alice Springs

best embodied the principles of comprehensive PHC—by a long way.

This is a remarkable achievement for an organisation that started in 1973 with

nothing, struggled to keep funded in the bureaucratic ghetto of Aboriginal affairs for

its first 20 years of operation, and only in 1996 was certified to receive support through

federal- and state-level funding mechanisms (i.e., Medicare), like other Australian health

services.

Congress has had to fight every step of the way in the most challenging circumstances this country has to offer, but they have succeeded. Although there is

still far to go, this is an Australian story worth telling.

CONGRESS IS . . .A community-controlled health service

that provides culturally respectful comprehensive PHC to Aboriginal people living in or near Alice Springs, or visiting the

town from much farther afield.

Today, Congress is one of the most

experienced Aboriginal PHC services in the

country, a strong political advocate of closing

the gap in Aboriginal health disadvantage

and a national leader in improving health

outcomes for all Aboriginal people.

SOUTHGATE INSTITUTE IS . . .An internationally renowned research centre,

located in the School of Medicine at the

Flinders University of South Australia, which

is concerned with the social, economic, political and equity aspects of public health policy, planning and implementation.

Professor Fran Baum, the institute’s

director, served on the Committee on Social

Determinants of Health of the United Nations’

World Health Organization (WHO), whose

2008 report set global standards.


ABORIGINAL HEALTH IN ABORIGINAL HANDS @ CENTRAL AUSTRALIAN ABORIGINAL CONGRESS 1

MESSAGE FROM FRAN BAUM, AO

Over my career in public health which

started in the mid-1980s I have

researched community health centres and

become an admirer of the ways in which

they have been able to put the principles

of the WHO’s Alma Ata Declaration on

comprehensive primary health care into

action. I have had the opportunity to

observe primary health care in many

settings around the world and it is evident

that Congress is an extraordinary model of good practice.

The Aboriginal Community-Controlled

health service model pre-dated Alma Ata

and was one of the social movements

which contributed to the original 1972

Whitlam Community Health Program. This

has been the only time that community

health has been at the front and centre of

national policy on primary health care.

The genius of the Aboriginal community controlled model is that it is able to take the best of a strong medical model of care and combine it with a social health model. As a Commissioner on the

Commission on the Social Determinants

of Health I saw the accumulated evidence

that good community health care has to

be based on an understanding of and

appropriate action on the social and

cultural determinants of health. Congress

stands out as an Australian service that

has managed to do exactly this.

People’s health is profoundly affected by the political and economic structures shaping their everyday lives. Opportunities for leading a

healthy and flourishing life are affected

by racism, the distribution of income,

wealth and employment and educational

opportunities. While a health service

can’t change those things they can take

account of their impact on individual’s

lives and play a crucial lobbying role.

They can also act to redress injustice and

health inequities through their style of

service provision.

Congress is a community-controlled model of comprehensive primary health care that needs to be acknowledged and celebrated. This report summarises

the research evidence which my team at

the Southgate Institute is pleased to have

produced in partnership with Congress

staff. We are very grateful for their trust

in allowing us to conduct this research

and congratulate the Board, community

and staff on their fine commitment to a

truly comprehensive primary health care

service. We would also like to acknowledge

the National Health and Medical Research

Council for funding the research (project

grant 535041), and the research team who

worked on the study, and who are listed

on the inside back cover.

We hope the report highlights what

makes Congress and other community

controlled health services like it special.

My vision is that every community in Australia would benefit from having such a service. National policy makers

should pay close attention to its benefits

and achievements.

Fran Baum, AO

Director, Southgate Institute

An Australian story worth celebrating

2

MESSAGE FROM DONNA AH CHEE

It’s been over 40 years since Congress

first opened the clinic on Hartley Street.

All the old people who fought for this

service, who worked so hard in the face

of so much opposition to make this

possible, would probably find it hard to

believe how far we’ve come. Not because

they doubted what our people could

do, but because the social and political

climate was so aggressively opposed to

what they were trying to do. A lot has

changed. Not enough, mind you, but a lot.

Congress is now a $40 million operation, with more than 300 staff who provide more than 160 000 episodes of care each year to about 12,000 Aboriginal people living in Alice Springs and in

six remote community clinics in Central

Australia.

In addition to this, the clinics service

over 4,000 visitors each year. One of

the best indicators of the success of

this comprehensive PHC approach is

the improvement that has occurred in

the health of children. When Congress started infant mortality rates were around 170 deaths per 1,000 live births and now they are around 12. Our

babies are no longer dying from easily

preventable causes and the challenge

has moved to the promotion of health

development. Since 2001, there has also

been about a 30% decline in all cause

mortality for Aboriginal people in the NT.

We have been able to achieve this because

right from the start Congress was based on PHC principles and understood the

need to address both access to quality,

multidisciplinary sick care and the social

determinants of health, because the

conditions of Aboriginal life clearly have a

huge impact on Aboriginal health.

Aboriginal people are the most over-

researched group in the country, but

this research conducted by Southgate

Institute for Health, Society and Equity

was important to us. Increasingly, research

is becoming our ally in the struggle to

improve health as it is being done in

accordance with the strategic priorities of

organisations like Congress. Congress’s policies and practices have always been evidence-based. Congress is appreciative

of the collaboration with the Southgate

Institute which has helped to demonstrate

so clearly what Congress is doing right.

I hope by reading this report both

Aboriginal health and the critical role that

community controlled comprehensive PHC

plays in health improvement will be better

understood.

Donna Ah Chee

CEO, Congress

Forty years of achievement


A big catchment

It’s impossible to appreciate Congress’s

achievements in delivering primary

health care without understanding how

large and varied its catchment area is.

Alice Springs and the network of town

camps in and around the municipality,

constitute the core. Aboriginal people live

both in the town and in the town camps.

However, the catchment also includes

remote Aboriginal communities—from

the Mutitjulu community at Uluru (Ayers

Rock) in the south to, Utju (Areyonga),

Ntaria and Wallace Rockhole communities

in the west and Ltyentye Apurte (Santa

Teresa) and Amoonguna communities in

the east—among which Aboriginal people

move and live. Finally, Aboriginal people

from other regions passing through Alice

Springs also use Congress’s services.

CONGRESS LOCATIONS IN

ALICE SPRINGS

• Head O�ce• Gap Road Clinic• Alukura Women’s Health Service• headspace Central Australia • Social & Emotional Wellbeing Service • Child & Family Service• Ingkintja Male Health Service ALICE

SPRINGS

MUTITJULU

LTYENTYE APURTE

AMOONGUNA

UTJUNTARIA

ULURU

Remote Health Service locations

LOCATION WITHIN NORTHERN TERRITORY

CONGRESS LOCATIONS IN CENTRAL AUSTRALIA

4

What’s inside . . . . . . key points

From its very inception Congress

embodied the core primary health

care principle of both treating sick

people and making them well through

multidisciplinary sick care while at the

same time addressing the underlying

socio-economic determinants of ill

health. For Congress it has always been

‘both / and’ and not ‘either / or’.

In the beginning it was about providing

emergency shelter through a tent

program, creating an accessible bank

that enabled enrolment for vital transfer

payments following the referendum

granting citizenship as well as running

a clinical service with GPs and the first

Aboriginal Health Workers. Now, Congress

sees approximately 10,000 urban clients

each year, providing about 130,000 unique

episodes of care (see Figures 1 and 2).

Congress has continued to combine the

provision of essential clinical services with

action on the broader social determinants

of health. The key points of this report are:

• Congress arguably represents the

Australian ‘gold standard’ for

community-controlled comprehensive

PHC that conscientiously addresses

social determinants in everything it

does, as it is able.

• 90% of staff interviewed by the

Southgate Institute said they take

the social determinants of health into

account in the course of their work.

• Nearly all staff surveyed (96%)

reported collaborating with other organisations in the course of

their work during the previous year,

including (in order of proportion

of contacts) hospitals, community

health services, NGOs, Centrelink,

schools, police, housing services, local

government / councils, the education

department, other PHC services, the NT

Medicare Local, private allied health,

private GPs, professional associations,

tertiary education institutions, divisions

of general practice—even the media.

• The vast majority of Congress clients

rated the quality of care at Congress

high or very high.

• In the diabetes case study, clients with

type 2 diabetes were ‘enthusiastically positive about the care they received’, and demonstrated good levels of

glycaemic control and blood pressure.

• Congress has helped Aboriginal

people in other areas of the country

to establish their own culturally appropriate health services.

• The Southgate Institute study

concluded that, of the six health

services investigated over five

years, Congress ‘provides a model’ for building into an organisation’s

governing structure the means for

community participation in decision-

making and service planning.

For Congress

it has always been

both treating sick

people and making

them well.


What’s inside . . . . . . key points

0

20000

40000

60000

80000

100000

120000

140000

160000

2008/09

2009

2009/10

2010

2010/11

2011

2011/12

2012

2012/13

2013

2013/14

2014

2014/15

2015

2015/16

Total

Figure 2. All Congress urban episodes of care, by year

EPIS

OD

ES O

F CA

RE

0

2000

4000

6000

8000

10000

12000

2007

2007-2008

2008

2008-2009

2009

2009-2010

2010

2010-2011

2011

2011-2012

2012

2012-2013

2013

2013-14

2014

2014-15

2015

Visitors

Health service area

Figure 1. Congress unique urban clients (service area and visitors), by year

NU

MB

ER O

F CL

IEN

TS

6

Primary health care . . . . . . a global paradigm shift still gaining ground

ALMA ATA DECLARATION The historical reference point for comprehensive PHC is the manifesto issued on

12 September 1978 at the end of a major international conference in Kazakhstan hosted

by the World Health Organization (WHO).

How PHC differs from traditional health care is easily understood in terms of ‘before’ and ‘after’ the Alma Ata Declaration, which:

• Articulated a new definition of health.

• Established health and access to health care as a human right.

• Included social, economic and political factors among those contributing to poor

health, meaning that solutions require a multi-sectoral approach, including the

recognition that there was a need for ‘a new economic paradigm’ in order to achieve

‘Health for All’. • Put responsibility on national governments for providing equal access to health

care, and developing the health workforce to meet greater demand.

• Advocated community participation in health care planning and implementation.

More selective variants of PHC have been introduced since, but the Alma Ata Declaration

remains the benchmark for comprehensive PHC.

Table 3. Conceptions of health care before and after the 1978 Alma Ata Declaration on Primary Health Care

BEFORE PHC AFTER PHC

Definition of health

Hard to define. Generally, the absence of disease or infirmity.

‘A state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity . . . ’ (Drawing on the 1947 WHO Constitution)

Focus of treatment

Symptoms of disorders or diseases exhibited in a patient.

A multifaceted individual who is unwell and is embedded in a context that may or may not support heath.

Status of health care

Public or privately funded services to which individuals may or may not have access.

Health is a socio-economic issue, and access to health care is a human right.

Approach Curative, rehabilitative. Health promotion, disease prevention, curative, rehabilitative.

Temporal duration Short-lived intervention. ‘ . . . ongoing process of improving people’s lives . . . ’

Socio-economic factors

Negligible. Critical.

Government’s role Variable. Responsible for ensuring all citizens have equal access to health care.

Health care policy Variable. National policies are required.

Sectors involved in health care

Health and medicine. Health and medicine, education, food supply and nutrition, water supply and sanitation, housing, family support and family planning, transport, public works, communication.

Role of the community

Negligible. ‘ . . . People have the right and duty to participate individually and collectively in the planning and implementation of their health care.’

The primary health care

(PHC) movement began

in the early 1970s out of

concern to correct massive

social and economic

inequalities between

rich and poor countries,

and between rich and

poor communities within

countries.

As a social justice-based

community development

movement gained pace

worldwide, it became clear

that inequalities in illness

and mortality rates result

from personal context within

communities characterised

by social, economic

and political inequality,

factors. That means some

communities and groups

have much less chance for a

healthy life than others.

This is especially so among

colonised Aboriginal and

Torres Strait Islander

peoples. Traditional health

services are ill-equipped

to address these social

determinants.


Primary health care . . . . . . a global paradigm shift still gaining ground

PHC IN AUSTRALIAThe principles of PHC began to be

formalised in Australia at a Monash

University conference in 1972. The

meeting, Better Health for Aborigines,

was convened by Basil Hetzel, inaugural

professor of social and preventive

medicine at Monash; Yami Lester, a

Yankunytjatjara man; and Jim Downing,

a Uniting Church minister. The first

Aboriginal community controlled health

service, Redfern Aboriginal Medical

Service, had been set up in 1971.

The topic was how to address shocking Aboriginal morbidity and mortality rates, often referred to as ‘third world’. The principles of PHC appeared to be the

only way to approach health problems

linked with such widespread disadvantage.

In 1973 the National Hospital and

Health Services Commission introduced

a community health initiative incorporating PHC principles. Although short-lived, the program led

to the incorporation of PHC principles in

Australian health policy and accreditation

criteria and a funding stream for

community controlled health services. The

Aboriginal community-controlled health

sector of which Congress is an exemplar,

continued to develop and grow. All of this

took place before the Alma Ata declaration

in 1978.

7

Runs on the board‘A PHC approach is the most efficient and cost-effective

way to organise a health system. International evidence

overwhelmingly demonstrates that health systems oriented

towards primary health care produce better outcomes, at lower

costs, and with higher user satisfaction.’ — MARGARET CHAN, DIRECTOR-GENERAL, WORLD HEALTH ORGANIZATION (2007)

Evidence for the effectiveness of PHC has been collected three times for the

Australian government in the past 15 years: the National Centre for Epidemiology

and Population Health (NCEPH) ‘Legge Report’ 1992, the ‘Griew Report’ (2008)

and Better Health Care (2001). All three reports conclude that comprehensive PHC

is the only strategy for addressing the overwhelming health problems faced by

Aboriginal people with a realistic prospect of success. Some observations:

• The main conclusion of the NCEPH report was that if the Australian health

system was re-oriented in accordance with the principles of primary health care

that this would lead to greater health improvement.

• ‘International experience has shown that a comprehensive approach to

primary health care can contribute to significant improvements in health in developing countries and among Indigenous populations in developed

countries comparable to Australia.’ (BHC, p. 11)

• ‘Evidence from the [USA] and New Zealand suggest that primary health care

has contributed to narrowing the life expectancy gap between Indigenous and non-Indigenous peoples in those countries . . . [and] that poorer access

to primary health care is associated with a widening life expectancy gap.’

(Griew, p. 7)

• ‘Improvements in Aboriginal and Torres Strait Islander infant mortality rates are consistent with better access to primary health care services’—

although they remain ‘almost three times greater than for other Australians,

and significantly worse than for those for Indigenous peoples overseas.’

(Griew, p. 7)

• ‘Changes in disease mortality patterns—including the shift from mortality due to infectious diseases to mortality due to chronic conditions’—are well-

documented, especially in the Northern Territory, ‘and are plausibly related to

the development and actions of primary health care services.’ (Griew, p. 7)

8

‘Our children have

dramatically different life

chances depending on

where they were born . . .

In countries at all levels

of income, health and

illness follow a social

gradient: the lower the

socioeconomic position,

the worse the health.

‘It does not have to be

this way, and it is not

right that it should be like

this. Where systematic

differences in health

are . . . avoidable by

reasonable action they

are, quite simply, unfair.’ —CLOSING THE GAP IN A GENERATION,

WHO COMMISSION ON THE SOCIAL DETERMINANTS OF HEALTH (2008)

DISCRIMINATION GENDER HOUSING RACISM JO

B +/– TRAN

SPORT EDUCATION SOCIAL CONNECTION POLITICAL / ECONOMIC CONTEXT

ACCE

SS T

O S

ERVI

CES:

san

itat

ion,

cle

an w

ater

, soc

ial, h

ealth

, training C

ULTURE

GROG DIET DRUGS SEXUAL H

EALTH EXERCISE VIOLENCE

OTHER H

EALT

H IS

SUES

S

MO

KIN

G

FAMILY

Social determinants of health . . . . . . context (really, really) matters

HEALTH BEYOND THE INDIVIDUAL Every person who seeks help from

Congress—or any health service—is

embedded in a context of daily life that

has multiple layers, all of which affect

health. The first layer involves immediate

or ‘proximate’ factors known to impact

health, many of which would be checked

in most medical settings. (See diagram

above.)

However, these proximate factors are

embedded in a larger social, economic and political context that powerfully

shapes the patient’s lived reality as well,

including health. If these environmental

factors are not addressed, they will

continue to adversely affect health.

Considerable lip service is paid to PHC

principles in health policy discussions

and drafting, but in reality most health

services worldwide run on a traditional

‘medical model’, – primary medical

care – which is designed to treat

defined conditions according to certain

therapeutic protocols. The medical model

places responsibility for health squarely

in individual behaviour (e.g., smoking,

drinking, overeating, not exercising

enough, following a doctor’s orders).

While PHC principles recognise the impact

on health of factors beyond the control

of the individual—e.g. housing, family,

education, income, culture, the availability

of transport—it is increasingly recognised

that health is not simply socially affected

but socially determined.

How a society is structured politically,

what sort of economic system it has, and

how these two work together with culture

to distribute not only public and private goods but also public and private goodwill—praise or blame, acceptance

or discrimination—also have a profound

impact on health, affecting different populations in different ways.


WHO COMMISSION MODEL OF HOW SDH AFFECT POPULATION HEALTH

Source: Closing the Gap in a Generation (2008)

Social determinants of health . . . . . . context (really, really) matters

SDH A PRIORITY @CONGRESS

• Website clearly sets out Congress’s

commitment to SDH. See: http://www.

caac.org.au/aboriginal-health/social-

determinants-of-health/

• 90% of staff interviewed by Southgate

Institute said they take SDH into account in

the course of their work.

• 59% of staff said SDH are taken into

account in Congress service planning.

• 67% of staff interviewed thought SDH are

on the Congress policy agenda.

• Examples include Congress’s advocacy on

alcohol supply through the People’s Alcohol

Action Coalition, a preschool readiness

program, a Men’s shed that provides job

skill training, and collaboration with the

housing authority on housing issues.

• Congress has long prioritised and carried

out research to ensure its approach to

health care is based on scientific evidence,

a key recommendation of the WHO

Commission.

‘Put simply, the social gradient

in terms of housing, education,

employment, access to justice and

empowerment are directly linked to

the disastrous health outcomes we

face.’ —REBUILDING FAMILY LIFE (CONGRESS)

Generally speaking, people living in

poverty, lacking education opportunity,

and disadvantaged ethnic minorities

that tend to be both, tend also to have

the worst health in a society. In part

due to the body’s automatic response to

psychological stressors, there is a cost

to health paid by people lower on the socioeconomic gradient that is not

incurred by people higher up.

Aboriginal people remain the most socioeconomically disadvantaged Australians.

RIO DECLARATION (2011)Under the auspices of the World Health

Organization (WHO), the Commission on Social Determinants of Health (SDH)

collected and analysed global evidence

for the impact of SDH on health, and the

health inequities arising from them.

In a 247-page report entitled Closing the

Gap in a Generation published in 2008, the

Commission concluded: ‘Social injustice is killing people on a grand scale.’ Doing

something about it should be an ‘ethical

imperative’ worldwide.

The Commission made 3 over-arching

recommendations, which provided the

backbone of the 2011 ‘Rio Declaration’ on

SDH produced by a world conference held

in Brazil to discuss the findings.

1) Improve daily living conditions.

Especially concerning the wellbeing

of girls and women; early childhood

development; education; and the

conditions in which people live and work.

2) Tackle the inequitable distribution

of power, money and resources in the

way society is organised, which produce

inequities in the social and material

conditions of life.

3) Measure and understand the problem,

and assess the impact of action. This

includes making SDH a greater focus of

public health research.

SOCIOECONOMIC AND POLITICAL

CONTEXT DISTRIBUTION OF HEALTH

AND WELLBEING

HEALTH-CARE SYSTEM

SOCIAL DETERMINANTS OF HEALTH AND HEALTH INEQUITIES

• Material circumstances• Social cohesion

• Psychosocial factors• Behaviours

• Biological factors

• Social position

• Education• Occupation

• Income• Gender

• Ethnicity / Race

• Governance

• Policy (Macroeconomic,

Social, Health)

• Cultural and societal norms

and values

http://www.caac.org.au/aboriginal-health/social-determinants-of-health/



10

Congress became a pioneer of comprehensive

PHC out of necessity,

not ideology.

Addressing the social

determinants of

health was the most

rational response to the

circumstances when

Congress was created,

not simply because

it coincided with a

worldwide movement.

Today, Congress arguably

represents the Australian

‘gold standard’ for

community-controlled

comprehensive PHC that

conscientiously addresses

social determinants in

everything it does, as it

is able.

Congress in context . . . . . . zero to comprehensive in 40 years

Congress is one of two organisations

created at an historic meeting of

Aboriginal people from many language

groups on 9 June 1973 in Alice Springs.

The Central Australian Aboriginal Legal Aid Service (CAALAS) was established

first to help Aboriginal people with the

legal troubles, and personal trauma, that

flowed from life in a social, economic and

political system alien to their culture,

which had taken their land, herded them

onto missions and reserves, and was

designed, in many respects, to control

their lives. Congress was the second.

Just as the Congress Party founded by

Mahatma Gandhi gave voice to Indians’

determination to be free from Great

Britain, so Congress was established to

be ‘the voice of Aboriginal people in Central Australia’—for a ‘fair go’ in every

other area of extreme disadvantage that

blighted Aboriginal life.

This included being forced to use health,

education and social services that were

insensitive —if not downright hostile—

to Aboriginal needs. The Alice Springs

Hospital was desegregated only four years

earlier.

It also meant that, right from the

beginning, Congress was charged with

looking after more than just Aboriginal health. Health was just one piece in a

multi-dimensional picture of deprivation.

FOUNDING PRINCIPLESCongress was founded on several

principles that set it on a collision

course with government policy. At the

time, policies discriminated between ‘traditional’ and ‘town’ Aboriginal

people on the basis of how much so-

called ‘Aboriginal blood’ an individual

possessed. Instead, the meeting declared,

Congress would operate according to the

following ideas:

• Town and bush are one mob.

• Anyone who identifies as an Aboriginal person is an Aboriginal person.

• Culture must be respected in all facets

of Congress’s operation and service.

• Community control is non-negotiable.



STARTING WITH NOTHINGCongress had a mandate to tackle a wide

range of problems, but no resources.

This meant asking for help. Intersectoral collaboration thus became another

standard of Congress’s operations.

The winter Congress was established was

very wet, and many Aboriginal people

had no shelter. The ‘Tent Program’ was

Congress’s first venture, with the help

of the Alice Springs Town Council and

charities like Anglicare. This was clear and

urgent way in which social and economic

factors were affecting health.

A ‘pick-up service’ was also established

to get drinkers out of public spaces

before they were charged with public

drunkenness, a difficulty faced by the

minority of Aboriginal people who drank

alcohol as pubs had ‘dress codes’ to keep

them out.

Monash University graduate Dr Trevor

Cutter arrived in 1974 to consult with

people and advise on the establishment

of a community health program. Cutter

was well-versed in the principles of the

emerging PHC movement, outlined at

a ground-breaking workshop at Monash

as the best hope for improving the

shockingly poor state of Aboriginal health.

Based on his wide-ranging consultations

and PHC principles, Cutter drafted

a funding submission to establish a

community health program as part of

the new established organisation which,

together with the existing non clinical

programs would create a new Aboriginal-controlled health service in Alice Springs.

Both NT and Commonwealth health

departments opposed the application.

FROM HARTLEY STREET (TOP) TO LEICHHARDT TERRACE

12

‘BETTER HEALTH FOR ABORIGINES’Despite this opposition, Congress officially

opened its clinic in dedicated premises on

10 October 1975 in a converted house on

Hartley Street.

Employment and training of Aboriginal Health Workers, to work as ‘cultural

brokers’ alongside the doctor, was an early

Congress innovation, as was a focus on

staff development, to train Aboriginal

people to take over administrative jobs.

In addition to the health clinic, Congress

operated a ‘welfare section’, which

initially helped people apply for benefits,

held the cheques of those with no postal

address, and ran a bank, as well as running

the pick-up service.

Over the years the welfare section

grew to encompass most of the social determinants of health, including

expanding access to housing, education

(school busing), nutrition (school

lunches, food vouchers), employment (via

CentreLink), transport, family support,

childcare, disabled and aged services,

dental services, remote outreach, and

alcohol rehabilitation—even assisting

with organising funerals.


managing chronic diseases may attend

the clinic up to four times per month.

From its earliest days, Congress became

a model of comprehensive PHC for

Aboriginal communities seeking to

establish their own health services, from

the Anangu Pitjantjatjara–Yakunytjatjara

(APY) Lands to Broome. Congress today

directly supports regional health services at Amoonguna, Uluru (Mutitjulu),

Areyonga / Utju, Hermannsburg (Ntaria)

and Santa Teresa (Ltyentye Apurte).

The remainder of this report shows how—and how well—Congress meets its continuing mission to deliver comprehensive PHC to Aboriginal people in Central Australia.

According to a history of the period,

Congress recorded about 4,000 medical

consultations its first year. The next year

the number of contacts for all services

more than doubled to 9,750. Within

a decade, the number had grown to

28,000 medical consultations, 1,200

dental consultations and 25,000 welfare

services—’approximately 190 people per

working day’.

It took two decades of dogged advocacy,

but in 1995 Congress finally joined the

relatively secure funding stream of

mainstream health services, including

access to Medicare (1996) and the

Pharmaceutical Benefits Scheme (1998).

A PURPOSE-BUILT MODEL Today Congress occupies a purpose-built

facility on Gap Road, from which it has

operated since 1988 and to which have

been added two adjacent blocks of land

and another block 5 kilometres away, as

programs and demand have expanded.

During the Southgate study period

(2009–2014), the number of individual

Congress clients grew 15%, from roughly

8,600 to 10,000. Each client may be seen

many times per year. Congress clients

‘[By] worrying about the

people, that’s how Congress

got so strong . . . [O]h, it

just amazed me how we

used to get these other

new programs goin’ . . .

with no dollars, no dollars,

absolutely no dollars.’ — MARGARET LIDDLE, SENIOR WELFARE

WORKER (1970s)



COU

RTE

SY O

F R

ED

BAC

KGR

AP

HIX

.CO

M.A

U

14

What we do . . . . . . activities and programs

THE CONGRESS VISION: All Central Australians enjoy the same level of health

CONGRESSMEMBERS

OUR CORPORATE SERVICES

OUR CLIENT SERVICES

OUR GOVERNANCE STRUCTURE

CONGRESSBOARD OFDIRECTORS

CEO

EXECUTIVEOFFICE

EDUCATION &

TRAINING

SERVICE

REMOTE HEALTH

SERVICES

SOCIAL &

EMOTIONAL

WELLBEING

SERVICE

CHILD & FAMILY

SERVICE

INGKINTJA MALE

HEALTH SERVICE

ALUKURA

WOMEN’S

HEALTH

SERVICE

GAP ROAD CLINIC

FINANCE

COMMUNICATIONS

INFORMATIONTECHNOLOGY &INFORMATIONMANAGEMENT

HUMANRESOURCES

PUBLIC HEALTHResearch

Continuous QualityImprovement (CQI)

INCLUDES:

Dentist

Medical Dispensary

Chronic Disease Program

Frail Aged and Disabled Program

Acute Care

Alice Springs A�er Hours GP

INCLUDES:

Women’s Clinic

Young Women’sCommunity HealthEducation Program

Family Partnership Program

Grandmothers and Aunties Program

Midwifery

INCLUDES:

Male Clinic

Men’s Shed

Young Men’s Community Health Education Program

Violence Intervention Program

INCLUDES:

Healthy Kids Clinic

Childcare

Pre-school Readiness Program

Intensive FamilySupport Program

Targeted FamilySupport Program

INCLUDES:

headspace (youth)

Cultural and SocialSupport Program

Therapeutic Program

INCLUDES:

Amoonguna Health Service

Ntaria Health Service

Mutitjulu Health Service

Mpwelarre Health Centre

Utju Health Service

INCLUDES:

Aboriginal Health Practitioner (AHP) Training

Traineeships

Congress’s corporate services help to keep our business running so that we can provide high quality services

to our people.

Congress’s Board of Directors is comprised of six member and three non-member directors. The member directors are

elected by Congress members and the non-member directors are appointed by the member directors for their specialised skill

in important areas of governance.

Congress is an Aboriginal community-controlled primary health care service. This means that we have a membership

of community members who help us to keep informed about the needs of our people.

Congress has over

40 years’ experience

providing comprehensive

primary health care for

Aboriginal people in

Central Australia.

Our services target the

social, emotional, cultural

and physical wellbeing of

Aboriginal people.


What we do . . . . . . activities and programs

THE CONGRESS VISION: All Central Australians enjoy the same level of health

CONGRESSMEMBERS

OUR CORPORATE SERVICES

OUR CLIENT SERVICES

OUR GOVERNANCE STRUCTURE

CONGRESSBOARD OFDIRECTORS

CEO

EXECUTIVEOFFICE

EDUCATION &

TRAINING

SERVICE

REMOTE HEALTH

SERVICES

SOCIAL &

EMOTIONAL

WELLBEING

SERVICE

CHILD & FAMILY

SERVICE

INGKINTJA MALE

HEALTH SERVICE

ALUKURA

WOMEN’S

HEALTH

SERVICE

GAP ROAD CLINIC

FINANCE

COMMUNICATIONS

INFORMATIONTECHNOLOGY &INFORMATIONMANAGEMENT

HUMANRESOURCES

PUBLIC HEALTHResearch

Continuous QualityImprovement (CQI)

INCLUDES:

Dentist

Medical Dispensary

Chronic Disease Program

Frail Aged and Disabled Program

Acute Care

Alice Springs A�er Hours GP

INCLUDES:

Women’s Clinic

Young Women’sCommunity HealthEducation Program

Family Partnership Program

Grandmothers and Aunties Program

Midwifery

INCLUDES:

Male Clinic

Men’s Shed

Young Men’s Community Health Education Program

Violence Intervention Program

INCLUDES:

Healthy Kids Clinic

Childcare

Pre-school Readiness Program

Intensive FamilySupport Program

Targeted FamilySupport Program

INCLUDES:

headspace (youth)

Cultural and SocialSupport Program

Therapeutic Program

INCLUDES:

Amoonguna Health Service

Ntaria Health Service

Mutitjulu Health Service

Mpwelarre Health Centre

Utju Health Service

INCLUDES:

Aboriginal Health Practitioner (AHP) Training

Traineeships

Congress’s corporate services help to keep our business running so that we can provide high quality services

to our people.

Congress’s Board of Directors is comprised of six member and three non-member directors. The member directors are

elected by Congress members and the non-member directors are appointed by the member directors for their specialised skill

in important areas of governance.

Congress is an Aboriginal community-controlled primary health care service. This means that we have a membership

of community members who help us to keep informed about the needs of our people.

16

Multidisciplinary teamwork . . . . . . key to quality care & client satisfaction

• 81% said quality care was ensured by

explaining all the treatment and

lifestyle options and letting clients

make the best decisions for themselves,

a practice reflected in clients’

evaluations of the service.

• Nearly all staff surveyed (96%)

reported collaborating with other

organisations in the course of

their work during the previous year,

including (in order of proportion

of contacts) hospitals, community

health services, NGOs, Centrelink,

ENSURING QUALITY CAREAs part of their evaluation of six primary

health care services, Southgate Institute

researchers surveyed 59 members of

Congress staff. Of those surveyed:

• 91.5% rated multidisciplinary

teamwork—having several health

experts with different skills and

expertise consulting on individual

clients’ cases—as the main mechanism

for providing high quality care. (See

diabetes case study opposite.)

SERVICE QUALITIES: MEETING A HIGH STANDARD Southgate identified several qualities comprehensive PHC services should have

besides the ideals of efficiency and effectiveness shared by all health services.

• Holistic. Treat the whole patient, not just disease symptoms.

• Mix of treatment, prevention & promotion. Community conditions and

common behaviour leading to ill health also must be targeted.

• Used by those most in need. The most powerless tend to be those with the

greatest health needs.

• Increases individual control. Client rights are clearly articulated. Individuals

better understand factors that affect health.

• Responsive to the local community. Through governance and other means.

• Supports and empowers the community. Seeing change as a result of having

input in turn changes attitudes.

• Culturally respectful. Affects service use and treatment.

On a 5-point scale, Congress’s clients ranked their service very highly (between

4 and 5) on six of the nine factors.

‘Staff are willing to listen

and they help by putting

you in touch with other

places and services or

programs available at

Congress.’ —CONGRESS CLIENT

‘I find with Congress that

they have access to a lot

more here than elsewhere

that I’ve been.’ —CONGRESS CLIENT

17

Multidisciplinary teamwork . . . . . . key to quality care & client satisfaction

schools, police, housing services, local

government / councils, the education

department, other PHC services, the NT

Medicare Local, private allied health,

private GPs, professional associations,

tertiary education institutions and

divisions of general practice.

• Over 90% said that they personally take

the social determinants of health

into account in developing treatment

plans for clients to a great (67%) or

moderate (23.5%) extent, and over half

(51.2%) said this was accomplished

both through collaboration with other

organisations and advocacy.

HIGH CLIENT RATINGSAs Southgate Institute researchers found,

Congress clients tend to have a high

opinion of the service. Of 82 Congress

clients surveyed:

• 35% rated Congress 5 out of 5 for the

overall quality of services provided,

while 48% gave a rating of 4 out of 5.

• 72.5% said that staff explain procedures, tests and results all of the

time (37.5%) or often (35%).

• 77% said they were provided with the information they needed all the time

(51%) or often (27%). Only 3.7% said

they got the information they needed

rarely or never.

• Nearly 3 out of 4 clients (74%) said

Congress staff listened to and respected their preferences often

(46%) or all of the time (28%).

• Over half of respondents (54%) said

they received help from Congress staff

with issues not directly related to a health complaint—e.g. transport,

access to benefits, housing, legal

matters, job training and childcare—

while 32% said they received such help

with more than one issue.

ABORIGINAL HEALTH IN ABORIGINAL HANDS @ CENTRAL AUSTRALIAN ABORIGINAL CONGRESS

CASE STUDY: DIABETESChronic diseases present the greatest societal burden in terms of health funding,

patient suffering and cost to the economy, and in recent years their treatment has

taken priority in national health policy. As part of their study, the Southgate Institute

looked at how each of the six health services handled these complex cases.

Congress saw 884 clients with diabetes in 2014–15, equating to a 14% prevalence

in the service’s catchment population. Researchers received permission from 30

diabetic clients to review their cases, of which 12 clients agreed to be interviewed.

According to the Southgate report, in comparison with the other services Congress:

‘[E]mployed the widest range of disciplines and arranged for visiting professionals,

allowing Congress to act much closer to a one-stop shop for clients with diabetes

compared to the South Australian services.’

• Saw clients four times as often (on average 4 times a month, compared to once

monthly for the SA services), and monitored cases more closely.

• Enlisted the greatest number of professions in case management: ‘all clients saw

at least 3 professions . . . with the majority (70%) seeing more than 5 professions.’

Of these, the most common seen were GP, pharmacist, diabetes nurse, podiatrist,

and optometrist.

• Took the most comprehensive approach to accessibility, ‘with the provision of

transport, Aboriginal Liaison Officers, phone support to clients, home visitation

and outreach, including Nephrocare for clients on dialysis.’

• Was more likely to refer clients to external health services for diagnostic tests.

Moreover, clients were ‘enthusiastically positive about the care they received’ and

described Congress workers ‘as ‘understanding’, ‘helpful’, ‘extremely informative’,

‘extremely friendly’, ‘very compassionate’, ‘very professional in their attitude’, and

‘very thorough’.’ Clients also said workers gave ‘clear messages’ and were ‘supportive’.

Congress’s health centre report for 2015 shows the clinical benefits of this care for

clients. About a third of the 1207 Congress clients with diabetes (32%) had good

glycaemic control (HbA1c ≤ 7%), which was equivalent to the Northern Territory

average for Aboriginal PHC, and 25% had high blood sugar levels (HbA1c ≥ 10%)

which is less than the NT average. This glycaemic control is important in preventing

cardiovascular, eye, and other complications from diabetes, including amputations.

54% of these diabetic clients also had good blood pressure control (< 130 / 80)

and this is also important in the primary prevention of heart disease and stroke.

Outcome data such as this was not collected in the other services in the study.

Finally, Congress helped to develop a video-based resource called The Diabetes Story, which is aimed at clients with low medical literacy levels and comprehension

of written material and is available in three Central Australian Aboriginal languages

as well as English.

18

How we do it . . . . . . governance & community participation

‘Having the evidence is

not enough; knowing

what ‘best practice’

is [is] not adequate.

The best of ideas, the

best of our knowledge,

must come from a well-

grounded base within

our communities . . .

[T]he evidence says that

community control has

superior outcomes in

primary health care than

solutions imposed from

elsewhere.’ —REBUILDING FAMILY LIFE (2011)

COMMUNITY CONTROL: HOW IT WORKSCongress was created by a community,

for a community, and has remained

community-controlled for over 40 years, often against powerful odds.

Community participation, one of the key

characteristics of PHC, has long been

acknowledged as the source of

Congress’s strength.

Every person over 18 years of age in the

Congress catchment area who identifies

and is recognised by the community as an

Aboriginal person is eligible to become

a member of Congress. Membership

is required to vote in elections for

Congress’s governing board. The

Congress website explicitly encourages

membership, which is free, and provides

everything necessary to apply.

Every year the membership elects 3 Aboriginal members to the board of 6

members that governs Congress. The six

community board members then recruit and appoint 3 specialist members, who

may be non-Aboriginal people, represent

disciplines relevant to Congress’s

activities: primary health care, finance,

and governance and administration.

The board, together with the CEO and

specialist members, meet every 6 weeks.

After every meeting, the board issues a communiqué summarizing the items

discussed and decisions made, which is

distributed to all members and is available

to all staff on the intranet.

In addition, community members can raise issues through board members or

Congress staff.

HELPING OTHERS TO HELP THEMSELVESAs one of the earliest community-

controlled PHC health services,

Congress has helped Aboriginal people

in other areas of the country to establish their own culturally appropriate health services.

1973 Central Australian Aboriginal Congress, Alice Springs

1977 Angarappa – later Urapuntja Health Service, Utopia

1977 Pitjantjatjara Homelands Health Service – later (1984) Nganampa Health Council, SA

1978–82 Lyappa Congress, Papunya

1978 Broome Aboriginal Medical Service (BRAMS)

1982 Kalano – later (1990) Wurli Wurlinjang Health Service, Katherine

1983 Pintupi Homelands Health Service, Kintore

1983 Ngaanyatjarra Health Service (WA)

1985 Anyinginyi Congress Aboriginal Corporation, Tennant Creek

1986 Imanpa Health Service

1986 Mutitjulu Health Service, Uluru

2000 Ltyentye Apurte Community Government Council Health Centre, Santa Theresa

2002 Western Aranda Aboriginal Health Corporation

2003 Utju Health Service (Areyonga)

2003 North Barkly Health Board (becoming part of Anyinginyi)

2003 WYN Health Board (handed back to the NT DoH)

‘[L]ook, we as a people in this community know that if we have an

issue with Congress . . . we feel like we could go and tell them. It’s not

a place that you’ve got to keep an arm’s length away.’CHR—CONGRESS CLIENT

How we do it . . . . . . governance & community participation

ADDRESSING THE SOCIAL DETERMINANTS THROUGH TRAINING AND EMPLOYING ABORIGINAL PEOPLEOne of the important ways Congress addresses social determinants is through

training and employing Aboriginal people. As of December 2015, Congress

employed 309 staff in full-time, part-time, and casual roles. Of these a total of

144 staff were Aboriginal (47%). The table below shows the Aboriginal staffing

level by division and by salary level.

Division Aboriginal Non-Aboriginal Total

Executive / Public Health 15 (60%) 10 (40%) 25

Business Services 7 (33%) 14 (66%) 21

HR 4 (50%) 4 (50%) 8

Health Services 118 (46%) 137 (54%) 255

Salary level

Level 1–2: Entry level roles 21 (78%) 6 (22%) 27

Level 3–5: Technical officer roles, Childcare, AHPs and admin levels

64 (81%) 15 (19%) 79

Level 6–7: Front line supervisors, experienced admin levels, new graduates RN

46 (73%) 17 (27%) 63

Level 8 and above: Management roles, GPs, tertiary qualified roles, allied health staff, experienced RNs

13 (9%) 127 (91%) 140

TOTAL 144 (47%) 165 (53%) 309

The reduced proportion of Aboriginal staff at the highest salary levels

highlights the challenges faced by a service like Congress in employing

Aboriginal people at the higher professional levels given the continuing failure to close the gap in early childhood education and school education to ensure there are sufficient Aboriginal people qualified at these levels. There

are jobs within a PHC service like Congress that require tertiary qualifications

yet there are not enough Aboriginal people qualified for these types of

positions. This is where the Congress traineeships, cadetships and study

support initiatives are important, as this is a pathway to assist Aboriginal people into tertiary level studies so that Congress can employ them in the

better paid roles.

SOUTHGATE STUDY: CONGRESS IS A MODELThe Southgate Institute study concluded

that, of the six health services investigated

over five years, Congress ‘provides a model’ for building into an organisation’s

governing structure the means for community

participation in decision-making and service

planning—not just for Aboriginal people

but for community-based health services

more generally.

Researchers found that health services run

by non-governmental organisations have

‘more mechanisms for accountability to the community’—for example, through

boards of management—than state-managed

PHC providers.

While community participation is mandated in state-managed PHC services, researchers

found that it was ‘less noticeable in practice,’ and actual opportunities for community

participation had contracted.

Community participation in state-managed

PHC services was ‘generally limited to individual feedback on specific programs,’ for example, on a particular consultation or as

part of a program’s means of assessment.

19ABORIGINAL HEALTH IN ABORIGINAL HANDS @ CENTRAL AUSTRALIAN ABORIGINAL CONGRESS

20

Advocacy . . . . . . collaborating to makes good things happen

MAKING THE VOICE HEARDBy assuming responsibility for ensuring

the health of Central Australian Aboriginal

people, Congress necessarily took on the

task of promoting Aboriginal people’s interests in many areas not traditionally

associated with health.

For example, the Tent Program, initiated

soon after Congress was established

in 1973 during a very wet winter,

immediately involved the organisation

in the lack of appropriate housing for

Aboriginal people in and around Alice

Springs as well as the lack of secure tenure over land on which to build

such housing.

Because Congress started with nothing,

from the beginning advocacy meant collaborating to bring about a

positive result. In the Tent Program, for

example, Congress got help from what

is now Anglicare and the Alice Springs

Town Council.

Shepherding applications for welfare

payments through relevant departments

and organising receipt of cheques for

distribution also forced Congress staff

right from the start to develop productive relationships with public servants in

many areas.

Advocacy is an important

characteristic of primary

health care that addresses

the social determinants of

health, but it usually is not

a primary characteristic

of most health services.

In Congress’s case,

advocacy was its first

mission—to be ‘the voice

of Aboriginal people in

Central Australia’—and

advocacy has permeated

its activities ever since. Today, collaboration with other

professionals and organisations

is Congress’s principal way of

fulfilling its mission.

HOW IT WORKSIndividual advocacy means accessing

the services needed, clinical and social,

to bring the whole patient back to

health, not simply to treat the symptoms

of a disorder. This may involve liaison

with other doctors or the hospital,

social services, employment agencies,

educational institutions, and organising

transport. It also means following up with

patients to ensure they have what they

need to attend appointments.

In fact, 96% of Congress staff interviewed

by the Southgate Institute reported

collaborating with other organisations in

the course of their work.

Community advocacy addresses the

social determinants of health through

support of land rights, adequate housing

and infrastructure, transport, education,

and employment opportunities, in

addition to community-based health

promotion campaigns, for example,

against smoking and domestic violence.


Advocacy . . . . . . collaborating to makes good things happen

Government advocacy takes place at

the local, territory, and federal level and

is often aimed at policy and funding.

Congress has enjoyed great success in this

area, long acknowledged by governments

and peers. The most important victory was bringing funding arrangements for Aboriginal health services under the Commonwealth department responsible for health. This massive shift, in 1995,

brought Congress’s clinical activities under

Medicare and the pharmaceutical benefits

scheme (like mainstream services), and

provided a level of funding security

unknown in Congress’s first 20 years.

VITAL ROLE OF RESEARCHResearch is now internationally

acknowledged as indispensable for

providing a solid empirical basis for health practice and assessing the effects of interventions. It is also

necessary to provide evidence for

advocacy. Congress was and continues to

be a pioneer in this area as well, mainly

because it had to be.

When the first Congress clinic opened

in 1975, it followed a new approach to

health care—through comprehensive PHC

that addresses the social determinants of

health. Little research had been done in Australia relative to this new model,

and nothing in relation to Aboriginal

people, so Congress took responsibility for

ensuring a scientific evidence base existed

for its innovations and practices.

As a result, qualitative and quantitative

research has always been an integral part of Congress’s activities, which is

relatively rare among health care services

Australia-wide. The current research

register outlining all of the projects

that Congress is engaged in is publicly

available through the Congress website.

PEOPLE’S ALCOHOL ACTION COALITION: TURNING DOWN THE TAP

‘Congress could never have done this on our own . . . I am quite

confident that we wouldn’t have got where we are now on the

issue of alcohol and getting the tap turned down if it wasn’t for

the collaborative nature of the work . . . ’— CONGRESS STAFF MEMBER

Statistics show that Aboriginal people

are more likely than non-Aboriginal people to abstain from drinking alcohol,

but Aboriginal people who do drink are

more likely to drink to harmful levels.

Where it is a major feature alcohol affects every facet of Aboriginal

family and community life—from

nutrition, employment and educational

performance to levels of violence, the

condition of housing stock and health.

This is why one of the first programs

Congress established was a pick-up

service, to get drinkers out of harm’s way

and prevent their arrest.

In Central Australia the history of

Aboriginal attempts to address alcohol

misuse has been marked by hopeful starts, dashed hopes and renewed effort. In 1995 a group was formed of

concerned individuals and organisations

long-experienced in dealing with the

harmful effects of alcohol. This group

ultimately became the People’s Alcohol

Action Coalition (PAAC).

In addition to concerned community

members, the PAAC includes official

representatives from Congress, the

Central Land Council, Aboriginal Medical

Services Alliance Northern Territory,

Northern Territory Council of Social

Services, Central Australian Youth Linkup

Service, Ngaanyatjarra, Pitjantjatjara

and Yankunytjatjara (NPY) Women’s

Council, Uniting Church, Public Health

Association of Australia NT, Mental

Health Association of Central Australia,

local church groups and trade unions.

The focus of PAAC’s actions has been

to restrict alcohol availability via

lobbying of the NT Liquor Commission to

introduce measures such as restricting

trading hours, reducing the number

(or opposing the expansion) of liquor

outlets, increasing taxes on particularly

harmful classes of alcoholic drinks (e.g.,

alcopops, flagons or cartons of cheap

wine), reducing taxes on less harmful

classes (e.g., beer), and registers of

banned drinkers at taverns, pubs, hotels

and takeaway liquor outlets.

One of the strongest, most consistent

research findings concerning alcohol consumption is its sensitivity to price and availability. When prices are lower,

consumption is higher. When prices are

higher, consumption declines. When

availability is greater, consumption is

greater. This is the case worldwide.

Under the slogan Turning down the tap

to bring down the harm, PAAC has had

some big wins and some losses but

since 2006 there has been a 28% decline

in per capita alcohol consumption (NT

Government, 2015). The PAAC website

(http://www.paac.org.au) provides the

latest news on these continuing efforts.

http://www.paac.org.au

22

MECHANISMS

• Accessible, locally delivered• Community driven

(community controlled)• Mix of prevention, treatment

and rehabilitation• Multi-disciplinary teamwork

(inc. AHWs) • Intersectoral and interagency

collaboration• Cultural respect• Promote economic paradigm

consistent with public health

INPUTS / RESOURCES• Sta, FTE, Funding

COMMUNITY CONTEXT

• Community’s needs,values and cultural practices

• Chronic disease epidemic• Resources available for health

in community• Education disadvantage

(including for employing sta)

SERVICE, GOVERNANCE & LEADERSHIP Service planning, monitoring, management, administration, development, capacity building for remote health, research, continuous quality improvement

HEALTH PROF. EDUCATION & TRAININGAHW training, registrar program, supporting medical, social work, psychological services, midwifery, nurse, AHW students, supporting juniors and OS doctors, encourage local doctors

CLINICAL SERVICES & PROGRAMSGP, pharmacy, chronic disease, hearing, children’s programs, frail aged and disabled, dental, specialists, immunisation, health checks, sexual health, allied health, preschool program, School Health/Trachoma Program, Renal Outreach Program, Health Lifestyle Program

WOMEN’S HEALTH (ALUKURA)Antenatal care, birthing, sexual health, ANFP program, specialist clinic, dispensary, health checks, cultural program, YWCHEP

SOCIAL EMOTIONAL WELLBEINGTherapy, youth outreach and drop in, Safe and Sober, targeted family support, FWBP, suicide prevention, community development, advocacy, Targeted Family Support Program, intensive Family Support Program

CPHC MECHANISMS EMBEDDED IN PROCESSES, SYSTEMS AND STRUCTURES

SKILLED, ACCOUNTABLE, SATISFIED WORKFORCE • Reduced rates of disease and

disability

• Reduced progress and impact of disease and disability

• People feel cared for

• Increased child and mental health

• Increased and promote women’s health

• Increased rate of healthy weight babies

HEALTH FOR ALL

SUSTAINABLE CPHC-ORIENTED HEALTH SYSTEM:

• Full Aboriginal employment at Congress

• Achieved Aboriginal community-controlled PHCs in all communities

IMPROVED HEALTH AND WELLBEING OF INDIVIDUALS AND THE COMMUNITY:

• Improved quality of life in our community

• Increased dignity of the community (through true holisitic service that encompasses social, emotional, self-worth, empowerment)

• Reduced avoidable premature mortality

• Increased equity in health, housing, income, employment and tertiary qualifications

ACTIVITIES SERVICE QUALITIES ACTIVITY OUTCOMES COMMUNITY OUTCOMES

SOCIAL JUSTICE & SOCIAL VIEW OF HEALTH

ORGANISATIONAL OPERATINGENVIRONMENT

• Physical work environment, infrastructure

• Complexity of interaction between Indigenous knowledge and culture and Western styles of professional practice in the context of 21st Century life

• Resources available for health in community

• Education disadvantage (including for employing sta)

SOCIO-POLITICAL CONTEXT• Political environment• Close the Gap• Northern Territory

Emergency Response

ADVOCACY & INTERSECTORAL ACTIONSupport development of ACC PHCs, improve models of ACC PHCs, intersectoral committees, e.g. AS Transformational Plan, PAAC, early childhood

MEN’S HEALTH (INGKINTJA)Health checks, drop-in centre, violence, sexual health, Men’s Shed, hygiene, cultural program, Nungkaris, health summits, community liaison

ADOLESCENT HEALTHHeadspace, youth advisory group, GP, psychological services, community development

REMOTE HEALTHRemote health services (direct and auspiced) including podiatrist, diabetic nurse, nutritionist, GPs, nurses, AHWs, AOD

CHILD CARELong daycare

This program logic model was developed in collaboration with the South Australian Community Health Research Unit (Flinders University) as part of the Comprehensive Primary Health Care in Local Communities project funded by the NH&MRC. For more information please visit http://bit.ly/CPHCproject

SERVICES THAT ARE:

• Encouraging of individual and community empowerment and dignity

• Responsive to community needs

• Holistic• E�cient and eective• Universal and used by

those most in need• Culturally respectful• Compassionate

• Community participation

• Build capacity for remote PHCs

• Local community health professionals

• Stable, skilled workforce

• Achieved change in SDH

• Strengthened ACC PHC field

• Reduced rates of STIs

• Reduced rates of violence

• Increased men’s health and wellbeing

• Increased social and emotional wellbeing in community

• Reduced rates of suicide

• Increased health, wellbeing of Aboriginal and non-Aboriginal adolescents

• Improved health, wellbeing access to health care in remote NT

• Improved outcomes for children

PER

SON

– A

ND

FAM

ILY

– CE

NTR

ED C

ARE,

CO

MM

UN

ITY

DEV

ELO

PMEN

T,

S

OCI

AL A

ND

PR

EVEN

TIVE

PRO

GR

AMS

GOVERNANCE

FAM

ILY

COMMUNITY

INDIVIDUALS

CON

TRIB

UTE

S TO

ACH

IEVE

MEN

T O

F

comprehensivePHC@Congress . . . . . . putting it all together

SOUTHGATE MODEL FOR

COMPREHENSIVE PHC:

CENTRAL AUSTRALIAN

ABORIGINAL CONGRESS

The Southgate Institute

developed this program

logic model to capture

the ways in which a

health service (in this

case, Congress) works,

the context in which

services are provided,

and their intended

outcomes. Elements

of the environmental

context can help or limit

a service’s ability to

enact the principles of

comprehensive PHC, which

in turn shape the activities

the service engages in,

the qualities the service

achieves, and thus

the community health

outcomes that are the

organisation’s goals.


MECHANISMS

• Accessible, locally delivered• Community driven

(community controlled)• Mix of prevention, treatment

and rehabilitation• Multi-disciplinary teamwork

(inc. AHWs) • Intersectoral and interagency

collaboration• Cultural respect• Promote economic paradigm

consistent with public health

INPUTS / RESOURCES• Sta, FTE, Funding

COMMUNITY CONTEXT

• Community’s needs,values and cultural practices

• Chronic disease epidemic• Resources available for health

in community• Education disadvantage

(including for employing sta)

SERVICE, GOVERNANCE & LEADERSHIP Service planning, monitoring, management, administration, development, capacity building for remote health, research, continuous quality improvement

HEALTH PROF. EDUCATION & TRAININGAHW training, registrar program, supporting medical, social work, psychological services, midwifery, nurse, AHW students, supporting juniors and OS doctors, encourage local doctors

CLINICAL SERVICES & PROGRAMSGP, pharmacy, chronic disease, hearing, children’s programs, frail aged and disabled, dental, specialists, immunisation, health checks, sexual health, allied health, preschool program, School Health/Trachoma Program, Renal Outreach Program, Health Lifestyle Program

WOMEN’S HEALTH (ALUKURA)Antenatal care, birthing, sexual health, ANFP program, specialist clinic, dispensary, health checks, cultural program, YWCHEP

SOCIAL EMOTIONAL WELLBEINGTherapy, youth outreach and drop in, Safe and Sober, targeted family support, FWBP, suicide prevention, community development, advocacy, Targeted Family Support Program, intensive Family Support Program

CPHC MECHANISMS EMBEDDED IN PROCESSES, SYSTEMS AND STRUCTURES

SKILLED, ACCOUNTABLE, SATISFIED WORKFORCE • Reduced rates of disease and

disability

• Reduced progress and impact of disease and disability

• People feel cared for

• Increased child and mental health

• Increased and promote women’s health

• Increased rate of healthy weight babies

HEALTH FOR ALL

SUSTAINABLE CPHC-ORIENTED HEALTH SYSTEM:

• Full Aboriginal employment at Congress

• Achieved Aboriginal community-controlled PHCs in all communities

IMPROVED HEALTH AND WELLBEING OF INDIVIDUALS AND THE COMMUNITY:

• Improved quality of life in our community

• Increased dignity of the community (through true holisitic service that encompasses social, emotional, self-worth, empowerment)

• Reduced avoidable premature mortality

• Increased equity in health, housing, income, employment and tertiary qualifications

ACTIVITIES SERVICE QUALITIES ACTIVITY OUTCOMES COMMUNITY OUTCOMES

SOCIAL JUSTICE & SOCIAL VIEW OF HEALTH

ORGANISATIONAL OPERATINGENVIRONMENT

• Physical work environment, infrastructure

• Complexity of interaction between Indigenous knowledge and culture and Western styles of professional practice in the context of 21st Century life

• Resources available for health in community

• Education disadvantage (including for employing sta)

SOCIO-POLITICAL CONTEXT• Political environment• Close the Gap• Northern Territory

Emergency Response

ADVOCACY & INTERSECTORAL ACTIONSupport development of ACC PHCs, improve models of ACC PHCs, intersectoral committees, e.g. AS Transformational Plan, PAAC, early childhood

MEN’S HEALTH (INGKINTJA)Health checks, drop-in centre, violence, sexual health, Men’s Shed, hygiene, cultural program, Nungkaris, health summits, community liaison

ADOLESCENT HEALTHHeadspace, youth advisory group, GP, psychological services, community development

REMOTE HEALTHRemote health services (direct and auspiced) including podiatrist, diabetic nurse, nutritionist, GPs, nurses, AHWs, AOD

CHILD CARELong daycare

This program logic model was developed in collaboration with the South Australian Community Health Research Unit (Flinders University) as part of the Comprehensive Primary Health Care in Local Communities project funded by the NH&MRC. For more information please visit http://bit.ly/CPHCproject

SERVICES THAT ARE:

• Encouraging of individual and community empowerment and dignity

• Responsive to community needs

• Holistic• E�cient and eective• Universal and used by

those most in need• Culturally respectful• Compassionate

• Community participation

• Build capacity for remote PHCs

• Local community health professionals

• Stable, skilled workforce

• Achieved change in SDH

• Strengthened ACC PHC field

• Reduced rates of STIs

• Reduced rates of violence

• Increased men’s health and wellbeing

• Increased social and emotional wellbeing in community

• Reduced rates of suicide

• Increased health, wellbeing of Aboriginal and non-Aboriginal adolescents

• Improved health, wellbeing access to health care in remote NT

• Improved outcomes for children

PER

SON

– A

ND

FAM

ILY

– CE

NTR

ED C

ARE,

CO

MM

UN

ITY

DEV

ELO

PMEN

T,

S

OCI

AL A

ND

PR

EVEN

TIVE

PRO

GR

AMS

GOVERNANCE

FAM

ILY

COMMUNITY

INDIVIDUALS

CON

TRIB

UTE

S TO

ACH

IEVE

MEN

T O

F

comprehensivePHC@Congress . . . . . . putting it all together

24

Ensuring the future

the needs of Aboriginal people and the conditions of Aboriginal life.

Low levels of education and employment also present barriers. Compared to 73% of non-Aboriginal Australians aged 15–64, only 44% of Aboriginal and Torres Strait Islander people have attained Year 12 or Certificate level II or above (ABS, 2013). Just over half (56%) of Aboriginal and Torres Strait Islander people in that age group are in the labour force, compared to 76% of non-Aboriginal Australians (ABS, 2013).

So long as racism continues to blight Aboriginal life, Aboriginal living conditions remain significantly deprived relative to the non-Aboriginal population, and Aboriginal health remains a national embarrassment, so long will there be a critical need for Congress and other Aboriginal community controlled health services.

For the first half of its life, Congress operated in an atmosphere of

continual uncertainty regarding funding for its programs. The second half has been much more secure, but challenges always exist , in particular to:

• expand programs to address the social determinants of health.

• conduct research to ground programs and practices scientifically.

• preserve an atmosphere of cultural respect.

Although all are important, preserving the atmosphere of cultural respect that makes Congress a safe place for Aboriginal people to attend is not only vital but also the most likely to be challenged in the future, as governments look for ways to cut health budgets or to competitively tender out services primarily on the basis of cost rather than respect for community control.

If they don’t feel comfortable Aboriginal people won’t attend a clinic, doctor’s office or hospital until the problem is very serious, and Aboriginal and Torres Strait Islander mortality and morbidity statistics remain a national scandal.

Aboriginal and Torres Strait Islander people die 10–17 years younger than non-Aboriginal Australians (ABS, 2011). By contrast, in the USA, Canada and New Zealand Indigenous people have a life expectancy only 7 years shorter, according to Oxfam Australia.

Moreover, a tendency exists for Australian policy-makers to make program and funding decisions based on research from abroad, which often does not reflect

‘More than 200 years

of institutionalised

dispossession, racism

and discrimination have

left Aboriginal and Torres

Strait Islander people

with the lowest levels of

education, the highest

levels of unemployment,

the poorest health and

the most appalling

housing conditions.’ — OXFAM AUSTRALIA

OLY

MP

IAN

CAT

HY

FREE

MA

N V

ISIT

S CO

NG

RE

SS, 2

012.

‘You can have people on what’s a really expensive maintenance

health program, that requires a high level of commitment to a

healthy lifestyle . . . [and] you’ve got people who are homeless, or

living in very overcrowded situations, with no ability to control their

diet or fluid intake . . . and [these] are the key factors [determining

whether] you do well on that program or not.’ — STAFF MEMBER, CONGRESS


Want to know more? Check it out . . .

WEBSITES

http://www.caac.org.au

http://www.flinders.edu.au/medicine/sites/southgate/

http://www.who.int/social_determinants/en/

http://www.who.int/publications/almaata_declaration_en.pdf

https://www.oxfam.org.au/explore/indigenous-australia/our-aboriginal-and-torres-strait-islander-peoples-program/

http://www.paac.org

RESEARCH TEAMSouthgate Institute for Health, Society and Equity• Prof. Fran Baum (CI)• Dr Angela Lawless (CI)• Dr Gwyn Jolley (CI)• Dr Toby Freeman• Dr Sara Javanparast• Ms Tahnia Edwards• Ms Zoe Luz• Ms Patricia Lamb• Ms Paula Lynch• Ms Helen Scherer

Other Chief Investigators• Prof. David Sanders, School of Public Health,

University of the Western Cape, South Africa • Prof. Ronald Labonté, University of Ottawa,

Canada• Prof. David Legge, LaTrobe University,

Melbourne

Associate Investigators• Ms Stephanie Bell, Dr John Boffa, Congress• A / Prof. Anna Ziersch, Southgate Institute • Ms Catherine Hurley, Southgate Institute

• Prof. Malcolm Battersby, Flinders University• Dr Michael Bentley, Southgate Institute• Dr David Scrimgeour, Aboriginal Health Council

of SA• Ms Kaisu Värttö, SHine SA• Ms Di Jones, Northern Adelaide Local Health

Network• Dr Pat Phillips, Endocrinologist• Ms Cheryl Wright, GP Plus Health Care Centre

Marion• Ms Theresa Francis, Southern Adelaide Local

Health Network

REFERENCES

ReportsCongress. (2011). Rebuilding Family Life in Alice Springs and Central Australia: the social and community dimensions of change for our people. Alice Springs. Central Australian Aboriginal Congress. http://www.caac.org.au/files/pdfs/Rebuilding-Families-Congress-Paper.pdf

CSDH. (2008). Closing the Gap in a Generation: Health equity though action on the social determinants of health. Final Report of the Commission on the Social Determinants of Health. Geneva, World Health Organization.

Griew, R., Tilton, E., Cox N. & D. Thomas, D. (2008). The link between primary health care and health outcomes for Aboriginal and Torres Strait Islander Australians: A report for the Office of Aboriginal and Torres Strait Islander Health, Department of Health and Ageing. Robert Griew Consulting. June. Waverly, NSW.

Oxfam Australia. (2007). ‘Close the gap! Solutions to the indigenous health crisis facing Australia.’ A policy briefing paper from the National Aboriginal Community Controlled Health Organisation and Oxfam Australia. Fitzroy, Victoria.

Rosewarne, C., Vaarzon-Morel, P., Bell, S., Carter, E., Liddle M. & Liddle, J. (2007) ‘The historical context of developing an Aboriginal community-controlled health service: a social history of the first ten years of the Central Australian Aboriginal Congress.’ Health & History 9:114–140.

Commonwealth Department of Health and Aged Care. (2001). Better Health Care: Studies in the Successful Delivery of Primary Health Care to Aboriginal and Torres Strait Islander Australians. Canberra.

Articles from the Southgate Institute research projectFreeman, T., Baum, F.E., Jolley, G.M., Lawless, A., Edwards, T., Javanparast, S. & Ziersch, A. (2016). Service providers’ views of community participation at six Australian primary health care services: Scope for empowerment and challenges to implementation. International Journal of Health Planning and Management, 31:E1–E21.

Freeman, T., Baum, F., Lawless, A., Javanparast, S., Jolley, G., Labonte, R., Bentley, M., Boffa, J. & Sanders, D. (in press). Revisiting the ability of Australian primary health care services to respond to health inequity. Australian Journal of Primary Health. Online Early, DOI: 10.1071/PY14180.

Freeman, T., Edwards, T., Baum, F., Lawless, A., Jolley, G., Javanparast, S. & Francis, T. (2014). Cultural respect strategies in Australian Aboriginal primary health care services: Beyond education and training of practitioners. Australian and New Zealand Journal of Public Health, 38:355–361.

Jolley, G., Freeman, T., Baum, F., Hurley, C., Lawless, A., Bentley, M., Labonte, R. & Sanders, D. (2014) ‘Health policy in South Australia 2003-10: primary health care workforce perceptions of the impact of policy change on health promotion.’ Health Promotion Journal of Australia, 25:116–124.

Anaf, J., Baum, F., Freeman, T., Labonte, R., Javanparast, S., Jolley, G., Lawless A. & Bentley, M. (2014) ‘Factors shaping intersectoral action in primary health care services.’ Primary Health Care and General Practice, 38:553–559.

Baum, F., Legge, D., Freeman, T., Lawless, A., Labonte R. & Jolley G. (2013). ‘The potential for multi-disciplinary primary health care services to take action on the social determinants of health: action and constraints.’ BMC Public Health 13:460.

Baum, F., Freeman, T., Jolley, G., Lawless, A., Bentley, M., Värttö, K., Boffa, J., Labonte R. & Sanders, D. (2014). ‘Health promotion in Australian multi-disciplinary primary care services: case studies from South Australia and the Northern Territory.’ Health Promotion International, 29:705–719.

Baum, F., Freeman, T., Lawless, A. & Jolley, G. (2012). Community development: improving patient safety by enhancing the use of health services. Australian Family Physician, 41:424–428.

Freeman, T., Baum, F., Lawless, A., Jolley, G., Labonte, R., Bentley M. & Boffa, J. (2011). ‘Reaching those with the greatest need: how Australian primary health care service managers, practitioners and funders understand and respond to health inequity.’ Australian Journal of Primary Health, 17:355–361.

Updates on the Southgate research on comprehensive PHC can be obtained from:Dr Toby Freeman ([email protected]) or

Project Director Prof Fran Baum ([email protected])

And by consulting the project website: http://www.flinders.edu.au/medicine/sites/southgate/research/primary-health-care-and-community-services/cphc/cphc_home.cfm

http://www.caac.org.au

http://www.flinders.edu.au/medicine/sites/southgate/

http://www.who.int/social_determinants/en/

http://www.who.int/publications/almaata_declaration_en.pdf

https://www.oxfam.org.au/explore/indigenous-australia/our-aboriginal-and-torres-strait-islander-peoples-program/

http://www.paac.org

mailto:[email protected]

mailto:[email protected]

http://www.flinders.edu.au/medicine/sites/southgate/research/primary-health-care-and-community-services/cphc/cphc_home.cfm



CONTACT CONGRESS:Central Australian Aboriginal Congress

PO Box 1604

Alice Springs NT 0871

Telephone: (08) 8951 4400

Fax: (08) 8953 0350

HOW TO CITE THIS REPORT:Pamela Lyon (2016). ‘Aboriginal health in Aboriginal hands: Community-controlled

comprehensive primary health care @ Central Australian Aboriginal Congress.’ Alice

Springs. Central Australian Aboriginal Congress.

DESIGN AND PRODUCTION:

Bruderlin MacLean Publishing Services


aboriginal health in aboriginal hands - flinders · pdf fileaboriginal health in aboriginal...

Documents